REPUBLIC OF THE PHILIPPINES

VETERANS MEMORIAL MEDICAL CENTER

PHIC ACCREDITED HEALTH CARE PROVIDER

MEDICAL RECORDS UNIT

CR-1
RECORDS OF HOSPITALIZATION
PATIENTS IDENTIFICATION Line 1- Patient’s Name (last, first, middle); ward unit; registry number
Line 2- C-number
Line 3- Transfer or Direct Admission Date
Line 4- Permanent Address (street, city or town and province)
Line 5- Birthplace, age, and date of birth
Line 6- Occupation; status; sex; religion
Line 7- Person to notify in case of emergency & relation to patient
Line 8- Address of person to notify and telephone number, if any.
ADMITTINNG DIAGNOSIS:

DIAGNOSIS NO. (ICDA) FINAL DIAGNOSIS (CLINICAL PATHOLOGICAL)

OPERATION NO. OPERATION AND PROCEDURES PERFORMED DURING DATE PERFORMED

THE CURRENT ADMISSION

SPECIAL STUDIES AND THERAPY

DISPOSITION DATE: To Be Completed By The Medical Records Unit:

Reason for Discharge: Disposition: Length of Hospitalization:

Discharged: _____________
Transferred to: AWOL: _____________ Admission Date: _______________
AMA: _____________
Died: _____________
CONDITION ON DISCHARGE OR TRANSFER: within 48 hrs: _____________ Discharge Date: _______________
after 48 hrs: _____________
Autopsy done:
Recovered: _________ Dis. Progressed: __________ Yes: _____________ Length of stay: _______________
Improved: _________ Diagnosis only: __________ No: _____________
Unchanged: _________ Died: __________

SIGNATURE OF WARD RESIDENT: APPROVED BY:

VMMC-MR_MAS-MRU FORM CR-1

REVISED JULY 2019